Healthcare Provider Details

I. General information

NPI: 1578868220
Provider Name (Legal Business Name): INDIANA PHYSICIAN MANAGEMENT-CLAY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2011
Last Update Date: 06/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1206 E NATIONAL AVE
BRAZIL IN
47834-2718
US

IV. Provider business mailing address

3946 SOLUTIONS CTR
CHICAGO IL
60677-3009
US

V. Phone/Fax

Practice location:
  • Phone: 317-802-3113
  • Fax: 317-870-0499
Mailing address:
  • Phone: 317-802-3113
  • Fax: 317-870-0499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: STEWART BICK
Title or Position: PRESIDENT
Credential: MD
Phone: 317-338-5053